Provider Demographics
NPI:1003925975
Name:WILBUR, LEE G (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:G
Last Name:WILBUR
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 COLONEL GLENN RD STE B
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-7731
Mailing Address - Country:US
Mailing Address - Phone:501-441-5558
Mailing Address - Fax:
Practice Address - Street 1:6221 COLONEL GLENN RD STE B
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-7731
Practice Address - Country:US
Practice Address - Phone:501-441-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058967A207P00000X
ARE8306207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR201811001Medicaid
INP00924303OtherRAILROAD MEDICARE PTAN
IN000000331511OtherANTHEM
IN200238230Medicaid
IN200238230Medicaid
IN160840HHHMedicare ID - Type Unspecified